Muggles is the term used at Hogwarts by Harry Potter and other students of magic for those with no magical abilities or awareness of the world of magic. I am proud to be a wizard. I am glad I can run my hands over someone's spine and muscles, and immediately know which ones are unhappy.
That said, I am also scientifically trained and believe in the scientific method. I like to stay up with the research and consider myself an evidence-informed practitioner.
Let's cut to the chase. What am I trying to say here? I know it has proven difficult to show that palpation and our various functional tests of joints are verifiable and reproducible. Some would say that makes all of manipulation unscientific and invalid, as we do not have a way of scientifically defining our primary lesion, the fixation / subluxation. The same statement could be made about soft-tissue work, as the lesion, trigger point or density within fascia is hard to prove or document.
This is quite the dilemma. I am not ready to throw out the baby with the bathwater. I am not willing to sell my birthright for a mess of pottage. I will continue to palpate, continue to use functional tests, and continue to get useful information. My patients will continue to marvel that I can find the hot spots so quickly, with such ease. This same tool set helps me determine whether my manipulation or exercise intervention is effective.
Is this "magic"? I don't think so. I think these "magical" skills are a combination of intuition and experience. I think if you don't believe these skills are useful, you will not develop the hands-on skills and are much less likely to become a great hands-on practitioner.
I don't want to rest on my laurels. I do not totally depend upon my palpation skills. I always attempt to cross-check. I want to provoke the pain, find a way to reproduce my patient's pain with a motion or touch. I always try to use additional physical assessment tools to confirm my findings. These cross-checks, in turn, help refine and improve my palpation and functional testing skills.
Laslett on SI Pain vs. Dysfunction
This thought process was stimulated by an article by Laslett,1 who sticks to a rigid, evidence-based approach. Laslett implies, based on his review of the literature, that all our tests of pelvic motion are useless and manipulation is not effective for SI pain.
I do think Laslett tells us something important. He is trying to differentiate true SI pain, noting what physical medicine tests (provocation tests) are useful to diagnose this. He differentiates true SI pain from SI dysfunction. He states that the research shows effective treatments for true SI pain include pelvic stabilization, exercise training and cortisone injections. Maybe we need to reframe our SI work.
I suspect that in the majority of cases, we are not treating true SI pain, but addressing SI dysfunction. In my experience, I see many patients who have SI dysfunction. These patients, wherever their pain is coming from, often respond to the combination of manipulation, soft-tissue and rehab many of us use. But the patient who only gets temporary relief, and needs the same area adjusted over and over, has not been properly assessed and treated.
In my opinion, it's rarely one source; there are usually many contributors to persistent pain. Flexion-intolerant lower backs with irritated discs often refer to the SI area. Thoracolumbar dysfunction with irritated cluneal nerves refers to the gluteal area, just lateral to the SI. The pelvis gets twisted out of alignment in almost all lower back pain. (My last article, "Sacroiliac Pain, A Complex Puzzle," makes some of these points. We overdiagnose the SI.2)
I cannot imagine treating lower backs without addressing SI dysfunction. I cannot imagine giving up my physical exam tools that attempt to define SI dysfunction, whether they are perfectly reliable or not.
McGill's Commentary on Clinical Test Reliability
A published commentary by one of my mentors, Stuart McGill, PhD, is a different take on a similar topic.3 Dr. McGill teaches back assessment as an art; a sophisticated way of using history, observation and physical exam to determine the source of lower back pain. His tools are not always "reliable" in the muggle science sense. I think he is implying that if we stop using all of the tools at our disposal, we will dumb ourselves down. What is going to give us the best results for the unique patients who present themselves to us?
Dr. McGill is an evidence-based researcher; his lab has done extensive basic research to more fully understand the biomechanics of lower back disorders. As a person who also functions as a clinician, Dr. McGill deeply understands the challenges of utilizing the history and physical exam to guide functional diagnosis and treatment. I quote extensively from Dr. McGill's commentary as follows:
"Musculoskeletal (MSK) disorders are different: their symptoms are highly variable in terms of pain, there is often more than one source of pain, the dosage of intervention is critical (as too much exacerbates and too little has no effect), and the outcomes are highly variable in terms of duration and effectiveness. Why should 2 clinicians obtain the same impression when examining a biological system that is continually in a state of flux?"
"Thus, the typical 'rules for reliability' associated with evidence-based medicine need a liberal amount of reflection for logical application in MSK situations. Machines can be extremely reliable, but no diagnostic machine (however reliable) has ever lived up to hyperbole or obtained a better outcome for MSK disorders than a highly skilled clinician. The best pattern recognition system, data integrator, decision processor, and manual applicator of corrective cues remains the skilled clinician."
"Clinicians have differing levels of clinical skill. Clinical skill involves perception of touch, interpreting what the patient verbalizes and displays with body language, knowing how much force to apply, knowing how to explore the end range and arc of motion with subtle trajectory variations to interpret joint capsule, bony interaction, ligament spring, and associated muscle tone, to name just a few variables."
I would contrast McGill's comments and approaches with Laslett's. McGill, to me, is a wizard, combining the evidence-based approach with elegant observation and physical exam tools and skills. I do not know Laslett; all I know about him is from reading this one article. But I fear some of his far-reaching conclusions represent the downside of overdependence on the limited evidence we have.
The science and art of patient care are constantly changing. To quote from a recent New York Times article4 on the state of psychology research: "Now, a painstaking years long effort to reproduce 100 studies published in three leading psychology journals has found that more than half of the findings did not hold up when retested.
"The vetted studies were considered part of the core knowledge by which scientists understand the dynamics of personality, relationships, learning and memory. Therapists and educators rely on such findings to help guide decisions, and the fact that so many of the studies were called into question could sow doubt in the scientific underpinnings of their work."
Common-Sense Chiropractic
I want to talk about us a bit, the chiropractic world. Chiropractors have come up with many fascinating ways to assess and diagnose. We seem to be masters of tools that help us digitize or create yes / no answers to our various questions. I think of Activator technique with its leg checks, I think of AK and the use of muscle-testing challenges. I have used and valued these kinds of tools over many years. I would, in the same breath, even include various forms of palpation, which seem more rational, but do not seem to be reproducible.
I want to warn you, in relation to your own decision-making: Don't believe your own BS. It is too easy to get seduced into thinking you know exactly what is wrong. It's too easy to come up with a story, a sequence that makes complete sense within your own little system. Don't believe it. You need to step outside your system and cross-check yourself. I often find myself starting over; re-examining and changing my working diagnosis when the patient fails to respond to my initial treatments.
I love Liebenson's model of the clinical audit.5 Within session, does your input change the functional test results? I appreciate Triano, et al.'s attempts to make sense of the various tools we use to figure out where to adjust:6 "In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care – methods involving pain provocation upon palpation or localized tissue examination." Let's use our common sense.
Yes, we want to honor and appreciate the evidence. No, unlike microbial diagnosis, our work does not lend itself to a black-and-white, evidence-based, rigid system. Become the grounded, common-sense wizard. Use both your left brain and your right brain. Learn to listen and observe. Good luck, and keep helping those patients.
In memoriam: A special thanks to Oliver Sacks, MD, who helped teach us to see each of our patients as a unique individual.
References / Notes
Laslett M. Evidence based diagnosis and treatment of the painful SI joint. J Man Manip Ther, 2008;16(3):142-52.
Heller M. "Sacroiliac Pain: A Complex Puzzle." Dynamic Chiropractic, July 15, 2015.
McGill SM. On the issue of clinical test reliability (invited commentary). Arch Phys Med Rehab, 2013;94:1635-37.
Benedict C. "Many Psychology Findings Not as Strong as Claimed, Study Says." New York Times, Aug. 27, 2015.
Liebenson C. "The Clinical Audit Process (CAP) Explained." Blog post, CraigLiebenson.com, April 13, 2015.
Triano J, et al. Review of methods used by chiropractors to determine the site for applying manipulation. Chiro & Man Ther, 2013;21:36.
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